Atrioventricular junction ablation in patients with conduction system pacing leads: A comparison of His-bundle vs
Ajay Pillai1, Jeffrey Kolominsky1, Jayanthi N Koneru1
1Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Virginia.
Insights
Left bundle branch area pacing (LBBAP) leads show better outcomes than His-bundle pacing (HBP) leads during atrioventricular junction ablation (AVJA) for atrial fibrillation. Conduction system pacing (CSP) preserves ejection fraction post-procedure.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Pacing
Background:
- Conduction system pacing (CSP) via His-bundle pacing (HBP) or left bundle branch area pacing (LBBAP) is feasible in atrial fibrillation (AF) patients undergoing atrioventricular junction ablation (AVJA).
- Previous single-center studies suggest feasibility, but direct comparisons are limited.
Purpose of the Study:
- To compare the outcomes of His-bundle pacing (HBP) versus left bundle branch area pacing (LBBAP) leads in patients undergoing atrioventricular junction ablation (AVJA).
Main Methods:
- Retrospective analysis of consecutive patients undergoing AVJA with CSP leads (HBP or LBBAP) between October 2014 and May 2021.
- Assessment of pacing lead characteristics, procedural details, complications, and long-term outcomes.
Main Results:
- 105 AVJA procedures were performed (55 HBP, 50 LBBAP).
- LBBAP group showed a higher acute success rate (100% vs 94%), shorter procedural and fluoroscopy times, and fewer lead-related complications (acute threshold rise, exit block, chronic high threshold, lead deactivation) compared to the HBP group.
- Conduction system pacing preserved ejection fraction overall and significantly improved it in patients with reduced baseline ejection fraction.
Conclusions:
- Atrioventricular junction ablation in the presence of a left bundle branch area pacing lead is associated with higher success rates and fewer complications.
- Conduction system pacing, using either HBP or LBBAP, effectively preserves left ventricular systolic function in patients with refractory atrial fibrillation post-AVJA.
Background:
Single-center studies have shown feasibility of conduction system pacing (CSP) via His-bundle pacing (HBP) or left bundle branch area pacing (LBBAP) in atrial fibrillation (AF) patients undergoing atrioventricular junction ablation (AVJA).
Objective:
The purpose of this study was to compare outcomes in patients with HBP and LBBAP leads undergoing AVJA.
Methods:
Consecutive patients with CSP leads referred for AVJA between October 2014 and May 2021 were included. Pacing lead characteristics, procedural characteristics, complications, and long-term outcomes were assessed.
Results:
One hundred five AVJA procedures (55 HBP, 50 LBBAP) were performed in 98 patients (48 HBP, 50 LBBAP). The acute success rate of the AVJA procedure was 94% vs 100% (P = .11) in HBP vs LBBAP groups. Seven (14%) redo AVJA procedures were required in the HBP group. Mean procedural time (44 ± 24 min vs 34 ± 16 min; P = .02) and mean fluoroscopy time (16 ± 18 min vs 7 ± 6 min; P <.001) were significantly longer in the HBP vs LBBAP group. An acute rise in threshold was noted in 8 cases (14.5%), and 4 (8%) developed exit block after AVJA in HBP patients. Chronic HBP threshold ≥2.5 V was seen in 23 patients (48%), and 4 (8%) HBP leads were deactivated. CSP preserved ejection fraction (EF) in the overall cohort (N = 70; 53% ± 10% vs 55% ± 10%; P = .09) and significantly improved in those with reduced EF <50% at baseline (N = 16; 37% ± 7.6% vs 46% ± 13%; P = .02).
Conclusion:
AVJA in the presence of an LBBAP lead is associated with a higher success rate and fewer acute and chronic lead-related complications. CSP with either HBP or LBBAP preserves left ventricular systolic function in patients with refractory atrial fibrillation post AVJA.
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